A fallacy-laden attack on science-based medicine, revisited

On Monday I took a blogger by the name of Dr. Marya Zilberberg to task for firing a series of profoundly anti-scientific broadsides against science-based medicine (SBM). Although I did not attack Dr. Zilberberg personally, I was quite harsh in my characterization of her attacks, because, well, they were quite bad, full of straw men, special pleading, and the claim that absence of evidence is not evidence of absence, all topped off with a particularly egregious mischaracterization of what SBM is. Steve Novella also piled on, which was appropriate because Dr. Zilberberg’s attacks were mainly directed at him.

ON MEANIES AND “TONE”

Yesterday, Dr. Zilberberg responded in a post she called Furthering the discussion. I, of course, am quite happy to further the discussion. However, before I do that, I, like Steve Novella, feel obligated to address the “tone” issue, because it comes up fairly frequently. First, I note that Dr. Zilberberg’s first response to criticism was actually quite dismissive. She accused Steve of doing “such a great job cherry picking” her arguments, and in response to Steve’s valid (in my opinion) complaint that he was tired of defending SBM against false charges of paternalism and arrogance, her response was “If the shoe fits.” Consequently, my response was tailored to Dr. Zilberberg’s original post. After all, she accused supporters of SBM of “arrogance” and “paternalism.” Indeed, her tone could not in any way be described as “civil,” her stated desire for a “civil discourse” notwithstanding. Seriously, if Dr. Zilberberg really wants a civil conversation, she has a rather odd way of showing it, particularly since I read other parts of her blog and saw evidence that this sort of nastiness is a pattern. For example, she’s referred to “rabid vaccine advocates,” accusing them of hysteria. Then she’s surprised when she receives responses that are as–shall we say?–as vociferous as a typical Orac response.
Don’t get me wrong. I love a good sarcastic throwdown more than the average blogger. After all, I cut my skeptical teeth on Usenet, that vast untamed discussion forum favored during the 1990s before the rise of weblogs and web-based discussion forums. There’s just one requirement that I learned well over a decade ago: If you’re going to be sarcastic, you’d better have all your ducks in a row. You’d better have the goods. You’d better have the science and evidence. There’s nothing more embarrassing than to get all sarcastic and self-righteous and then not have the goods to back it up. That’s exactly what happened with Dr. Zilberberg’s little broadside against SBM, as Steve and I demonstrated. Unfortunately, Dr. Zilberberg can’t seem to resist coming back for more. Fortunately, she appears to have realized her mistake, at least in that respect.

ON THE EVIDENCE BASE BEHIND SCIENCE- AND EVIDENCE-BASED MEDICINE

Issues of tone aside, Dr. Zilberberg’s arguments in her response are only marginally better than in her original post, beginning here:

I do believe our views are more same than different. We both (SBM group and I) understand that science evolves, that evidence is not stagnant and the sense of certainty frequently conveyed to the lay public by the media is oftentimes misplaced. We simply disagree on the extent to which there is uncertainty in evidence. While it is true that the oft-cited 5-20% number representing the proportion of medical treatments having solid evidence behind them is very likely outdated, the kind of evidence we are talking about is a different matter.

The problem is that that 5-20% number, which by the way is beloved of quacks and cranks, is a myth, as Steve Novella described three years ago. Bob Imrie tracked down the origin of this myth ten years ago and found that it dates back to a small survey of primary care offices in England back in 1961. Worse, the survey didn’t even really look at the evidence base behind practices; rather it was designed to look at prescribing practices and costs related to prescription drugs and generic drugs. It turns out that the numbers are much higher, ranging from 97% of anesthesia practices (32% by randomized clinical trials, RCTs) to 84% of internal medicine practices (50% by RCTs), with an average of 76% of interventions being supported by compelling evidence and 37% by the “gold standard” randomized clinical trials. Obviously, there is some subjectivity in deciding what constitutes “compelling” evidence, but by any reasonable standard it’s far higher than 5-15%. Even if you demand only randomized controlled trials as your standard of evidence, it’s far higher than 5-15%.

Contained within Dr. Zilberberg’s response is a more reasonable discussion of levels of evidence. For the most part, albeit with a rather negative spin compared to what I consider to be appropriate, she is correct when she points out that RCTs are often difficult to generalize and that metanalyses share the same sorts of problems, given that they are made up of multiple RCTs analyzed together. She is also correct that physicians often go beyond the indications supported by RCTs in presecribing treatments. However, I have a hard time viewing this problem as being more of a problem of physician education than a problem necessarily inherent in SBM. In any case, what strikes me about Dr. Zilberberg yesterday as opposed to Dr. Zilberberg several days ago is that she seems to be arguing that applying science to medicine is messy and difficult, which is something I’ve said all along and utterly not a point of contention. Remember, too, that in her first posts she characterized those of us who support SBM as being far too confident, dogmatic, and sure of the evidence, which both Steve and I both pointed out is not the case. She accused SBM of being far too “paternalistic” because of this alleged overconfidence in science and evidence and our interpretation of the evidence as being far too simplistic. My tendency towards sarcasm aside, I can’t recall ever arguing that medicine and applying scientific evidence to medicine is straightforward or simple.

Where Dr. Zilberberg goes wrong is in her own self-admitted penchant for observational data:

The next rung of the evidence ladder is observational data, specifically cohort studies first prospective, then retrospective. I am actually a great fan of observational data, as I have mentioned in the past. Cohort studies give us the opportunity to examine what happens in the real world without imposing artificial conditions necessary in a clinical trial. Observational data can be great when describing epidemiology of a particular disease, the frequency of a given exposure, how different characteristics can modify the relationship between the exposure and the outcome. One of the most attractive features of cohort studies is that the population can be observed over long period of time — just look at the Nurses’ Study, the Framingham Cohort, and others. But these types of studies also have important limitations, and these are readily acknowledged as a heightened susceptibility to bias (especially in the retrospective studies), the possibility of misclassifying important events, and, despite our best efforts to adjust for it, residual confounding. I will come clean and admit my affection for observational data, even despite the fact that it is lower on the totem pole of evidence than an RCT.

Observational studies can indeed be important. Even more importantly, sometimes for ethical reasons RCTs are not possible. When that’s the case, we have to rely on observational data of the type so beloved of Dr. Zilberberg. However, there is a problem. Such studies are are far more prone to confounders and bias. Worse, really big observational studies, like Nurses’ Study and the Framingham Study, are extremely expensive, costing many millions of dollars each. It’s often just not feasible to do huge observational studies of this sort for any but the most common conditions. Personally, I consider it a big mistake to be so fond of observational studies. They can tell us a lot, but their limitations are such that RCTs should be done whenever justified by preclinical data and financially feasible. The bottom line is that each type of study has its place based on its unique strengths and weaknesses. Moreover, as I hope Dr. Zilberberg would agree, one characteristic of pseudoscientists is that they drill down on individual studies, demanding “just one study” that “proves” the point that an advocate of evidence-based medicine (EBM) and SBM is arguing. It’s not that easy. It takes a convergence of evidence from multiple studies, all leavened with a consideration of all sources of evidence, including basic science.

Which is all we are saying when we refer to SBM, that all scientifically valid sources of evidence need to be considered.

ON “ALLOPATHIC” MEDICINE

Regarding CAM, Dr. Zilberberg tries to clarify what she was arguing (which she really needed to do because what she was arguing was a fetid load of dingo’s kidneys). Unfortunately, she can’t resist another swipe at “allopathic” medicine:

I will try to tackle my CAM argument next. If I in any way implied in my remarks that I encourage allopathic physicians (by the way, I am not using it in a derogatory way, but merely as it is defined here; in fact, until today I was blissfully unaware of its negative connotation) to be purveyors of CAM, I sincerely apologize.

This borders on a not-pology. Personally, I find it hard to believe that Dr. Zilberberg was “blissfully unaware” of the negative connotations of the term “allopathic” physicians given how often I’ve now seen her use the term while castigating SBM for “arrogance” and other shortcomings. Personally, I’d suggest that if she is so unaware of the negative connotation of the term, she is currently too uninformed to be blogging about such topics and should refrain from doing so anymore, at least until she educates herself a bit more on the basics of the tactics and arguments of CAM advocates used to distort evidence and science. Of course, if you check out the link she uses to define allopathy, I fail to see how Steve and my criticism of her for using the term “allopathic physicians” wasn’t spot on. After all, that link defines “allopathic medicine” thusly:

The system of medical practice which treats disease by the use of remedies which produce effects different from those produced by the disease under treatment. MDs practice allopathic medicine. Also called conventional medicine.

The term “allopathy” was coined in 1842 by C.F.S. Hahnemann to designate the usual practice of medicine (allopathy) as opposed to homeopathy, the system of therapy that he founded based on the concept that disease can be treated with drugs (in minute doses) thought capable of producing the same symptoms in healthy people as the disease itself.

Which is exactly the definition that Steve and I pointed out. Seriously, using a definition that the creator of what is arguably the quackiest of quackery, homeopathy, used to describe medicine is not derogatory? Does Dr. Zilberberg read various CAM sites? How could she not be aware that the term “allopathic” is a frequently used derogatory term to describe science-based medicine. Oh, well.

ON VACCINES AND UNWITTINGLY GIVING AID AND COMFORT

Dr. Zilberberg finishes up with two issues. First, she restates her position on CAM. Second, she is very unhappy at how some commenters have characterized her as “anti-vaccine.” I’ll deal with the second one first because it’s quicker:

My final words will be about vaccination. It is disheartening to be lumped with “anti-vaxers”, as has been done in the comments to Dr. Novella’s and Orac’s posts. While my bruised ego will survive this insult, I would like to question this assertion. Nowhere have I said that vaccinations are a bad idea or present a real danger to our children. The hype surrounding the vaccination-autism “debate” is abhorrent to me.

That’s a reasonable start. However, there is a strain of antivaccine thought that argues that vaccines are useless or that their benefits are hugely exaggerated and then using that argument to dismiss vaccination programs, often those for vaccines with a less compelling indication than, for instance, the measles vaccine. Kind of like this:

What I have stated, however, is that I am of the opinion that we have gone a bit overboard with some of them, one being the chicken pox vaccine. Now, this does not make me an “anti-vaxer”; this just makes me a bit skeptical. The way I view the data is that the advantages for this vaccine are mostly economic, in that they prevent parents from missing days at work. Now, I am certainly not opposed to making such a vaccine available to parents who desire it, but I am not convinced that it should be a prerequisite for my kid to go to school. Given that there is always a possibility of an adverse reaction, no matter how small that possibility is, if the risk of it may outweigh the benefit (and here I do not mean the benefit of having mom show up at work), it has to be weighed very carefully.

No one argues otherwise, really. I mean, is there anyone out there who argues that risks and benefits of vaccines shouldn’t be weighed carefully in determining vaccination policy? Admittedly, though, readers pointed out that Dr. Zilberberg had shown up in the comments of a post of mine from three months ago critizing an anti-vaccine quackery site claiming that the “whole thing feels like a schoolyard brawl,” accusing me of “parochialism,” and “hiding behind ‘evidence is on my side’ arguments.” Moreover, as part of that discussion, she wrote:

E.g., vaccinations: overall a very useful public health intervention under certain circumstances (life-threatening diseases, high contagion potential), safe when examined as single exposures. It is difficult to study potential interactions with other exposures, be it vaccines or something else, as well as long-term consequences. So, while some conclusions are warranted others are less obvious.

I realize that Dr. Zilberberg probably doesn’t realize it, but this line of argument comes perilously close to Jenny McCarthy’s beloved “too many too soon” slogan. Let me also say that I believe her when she says she is not anti-vaccine. Even so, she carelessly throws around rhetoric that, whether she realizes it or not, echoes a lot of anti-vaccine rhetoric. (And who is more of an expert on anti-vaccine rhetoric than I? Not many.) As Steve so aptly put it, what she’s doing is akin to someone expressing skepticism towards some aspect of evolution and thereby appearing to support creationism because she didn’t know the ways creationists distort and abuse science in the name of attacking evolution. She does the same thing here with vaccines. For example, elsewhere on her blog, as I mentioned before, Dr. Zilberberg referred to “rabid defenders of vaccines,” while complaining about the lack of philosophical exemption laws in most states. Let’s put it this way. If you don’t want to be perceived as an anti-vaxer, don’t refer to defenders of vaccines as “rabid” and don’t start referring to the possibility of vaccine interactions in a way that is reminiscent of the arguments that anti-vaccine advocates make. I realize that Dr. Zilberberg’s mistake is probably due to ignorance of the corrosiveness of the anti-vaccine movement, the depths of pseudoscience to which it regularly descends, and a lack of familiarity with their fallacious arguments, but hopefully this exchange will serve to educate her to be more careful in the future.

ON THE EVIDENCE BASE FOR CAM

When Dr. Zilberberg revisits the CAM issue, she uses one of the most irritating arguments that CAM apologists like to use, namely “What’s the harm?” It’s tempting simply to refer her to What’s the Harm?, but that’s a bit of the lazy way out. So would referring to Steve’s post that apparently provoked this whole exchange. Yes, many CAM therapies cause direct harm. Some cause harm by omission, by either interfering with or preventing effective conventional therapy. Then there is the harm that comes from teh erosion of the scientific basis of medicine that mixes pseudoscience with science to the point where it is hard to differentiate the two without considerable background knowledge. Besides being ignorant of how chiropractic is (and is not) regulated, Dr. Zilberberg also makes the rather bizarre argument that herbs should not be regulated because they grow naturally and we don’t generally regulate what patients grow in their backyard, except for marijuana. The problem is that most patients don’t grow their herbs in the backyard; they purchase them in the form of supplements. Moreover, this is not strictly an issue of regulation. There’s no need for a regulation to tell a patient using herbs grown in his backyard to treat cancer that the herbs won’t cure his cancer and to strongly suggest that the patient stop using them.

Perhaps the most puzzling passage is this:

What is coming through for me is that perhaps my call to equipoise was a little over the top, as I do not seem to be approaching the above CAM issues in a frequentist, but more in a Bayesian way (though I remain committed to equanimity). Yet, there is something to be said about the frequentist approach, even though it is not my way generally. The frequentist approach, which is what underlies the bulk of our traditional clinical research, does not rely on differential prior probabilities for different possible associations, but treats them all equally. Despite many disadvantages, one obvious advantage is that we do not discount potential associations that do not have biologic plausibility, given our current understanding of biology, and sometimes help us stumble on brand new hypotheses. So, clearly, there is a tension here, and I am still working on what is the better way, if any.

I was having a bit of a hard time figuring out just what Dr. Zilberberg was driving at here. Underlying Dr. Zilberberg’s argument seems to be the assumption that those of us who advocate SBM incorporating prior plausibility into analyses of possible associations think that determining these prior probabilities is straightforward. I doubt you’ll find a single SBM advocate make such a claim. What we argue is that exceedingly implausible prior probabilities should be treated that way–as exceedingly implausible. That includes modalities like homeopathy, reiki, and therapeutic touch, among others. Herbs and many other CAM modalities with a physical effect and potential mechanism of action that doesn’t violate multiple laws of physics Ã la homeopathy can arguably reasonably be treated by frequentist approaches. Herbs would be one example of that, actually.

Her denials notwithstanding, it is obvious that Dr. Zilberberg has a definite sympathy for CAM. Indeed, in another post entitled Allopathic medicine and CAM: Nonoverlapping magisteria revisited?, Dr. Zilberberg explicitly likens the conflict between SBM and CAM to the conflict between science and religion as exemplified by the conflict between defenders of evolution and creationists. She even argues that SBM (or “allopathic medicine,” as she puts it) and CAM are, as Stephen Gould so famously argued about science and religion, nonoverlapping magesteria. My guess is that she doesn’t realize quite how appropriate likening CAM to religion is, given that so much of CAM either derives from religious ideas (reiki, for instance) or prescientific beliefs about how the body works (acupuncture and much of traditional Chinese medicine). The money passage, however, is this:

Since we live in a time when polarization seems to be the norm (just look at our political discourse), it is natural for allopathic medicine and CAM to retreat more deeply into their own corners and to become more entrenched in and convinced of their own singularity. This is the wrong approach. Humans are not all easily-understood physiology, but we are also not all spirit and mystery. We are in fact both. Some of the conditions we define as physiologic illnesses are nothing more that the products of our distorted expectations and philosophies. Some of our impulses to treat cancer with CAM alone are misinformed. If acupuncture seems to help my neighbor with her subjective symptoms of menopause, so be it, I am happy for her, even if I do not fully understand how it works. If yoga gives me a sense of well-being, yet there are no randomized controlled trials to validate this assertion, so what?

This is yet another straw man argument. Actually, I’ve heard Kimball Atwood, for instance, say something very similar about massage: If it feels good, go for it. He even said at TAM8 that he sees no reason to do randomized clinical trials to demonstrate that massage feels good, and I had a hard time disagreeing with such an obvious assertion. The claim that defenders of SBM call for clinical trials on self-evident issues like that is a straw man. The problem advocates of SBM have with modalities such as massage, yoga, and other similar modalities is when they are represented as therapeutic modalities that treat specific conditions. When that happens, a claim is being made that these are therapies, rather than exercises or modalities that make you feel good (or “gives you a sense of well-being,” as Dr. Zilberberg puts it). In that case, there is a claim for therapeutic effect that should be tested before physicians should be recommending it. Moreover, clearly Dr. Zilberberg has tendencies towards mind-body dualism and is appealing to spirit and mystery, which may explain much of her “openmindedness” to the point of having her brains fall out. Personally, I’d be very interested in her evidence supporting the view that we are both “easily understood physiology” and “spirit.” Given how much Dr. Zilberberg pooh-poohs the evidentiary basis of modern medicine as being so weakly based in verifiable science, one can’t help but respond to her assertion with, “Pot. Kettle. Black.”

Perhaps the most disturbing aspect of Dr. Zilberberg’s argument is that she is arguing the entire issue from a false assessment of equality between SBM/EBM and CAM, or “equinamity” and “equipoise,” if you will. True, she does seem to back away from the equipoise in her latest post, but she’s also holding firm to advocating an equanimity that is not deserved, at least not on the basis of science. Regardless of whether Dr. Zilberberg realizes it or not, even in “frequentist” analyses of various interventions for diseases and conditions, we do, at least intuitively, consider prior probability, just not formally or necessarily explicitly. Basically, before the rise of CAM, scientists were unwilling to spend scarce medical research dollars and their own limited time studying interventions that had a very low (or even close to nonexistent) likelihood of being validated. Now, we spend millions of dollars on such studies, not because the science compels us but because ideology makes it attractive to do so.

Fortunately, I sense that Dr. Zilberberg appears to realize that she may have overstated her argument, at least in the way she seems to be backing off from stating that we should a priori show “equipoise” to all therapeutic modalities. Unfortunately, in considering CAM versus SBM, she continues to fall into the same trap of asserting dualism, a concept that is, like so many religion-inspired concepts, rapidly falling prey to science, in this case, advances in neuroscience, and arguments from ignorance or the unknown like this. She even recognizes that she is appealing to mind-body dualism:

But what are we unable to measure? Oh so much! The burgeoning science of neurobiology, for example, has raised so many interesting questions about not only what the mind can do to the body, but what the body can do to the mind (please forgive this dualistic language). Why is this important? Because, due to our lack of adequate tools until recently, and because of the overwhelming complexity of the subject, we have traditionally neglected to include any measures of our patients’ and trial subjects’ neurobiological milieu into the consideration of differences between groups. But if randomization takes care of other systematic differences, should it not take care of the neurobiological ones? Perhaps, but without understanding the magnitude of variability of these characteristics in a population, one cannot begin to know how large a swathe of the population has to be enrolled in a study in order to smooth out these potential differences. And this goes for other so far unknown or unidentifiable characteristics.

In other words, because we can’t measure everything about the brain and how it interfaces with the body, woo must work (or, more correctly, we can’t prove that woo doesn’t work). That’s what much of Dr. Zilberberg’s viewpoint with respect to CAM appears to come down to. Until she can let go of her dualism and appeals to things that science can’t measure, I fear that we will be talking past each other.

Since, for many dieases or ailments, there is a limited window in which real treatment can either offer a cure or remission (particularly cancer, before it metasticizes, the delay or rejection of treatment can and does prove fatal – and often the patient spends the last months of their lives in adject misery.

What, no reference to Semmelweis? And I half-expected to hear about Tom Jefferson’s oft-quoted reports on vaccines’ “inefficacy”. However, I’ll see that gould reference and raise you a feynman : “you must not fool yourself, and you are the easiest person to fool”.

As a scientist but not medical scientist, I’ve always wondered about the placebo effect. How do you guys deal with it in clinical trials and is it indicative of anything of importance in the context of ‘alternative medicines’?

Well, she didn’t decide to go for CAMs, actually. She was just afraid to go for surgery (as anyone could be) and missed the time window during which her tumor could have been worked on by conventional treatments. Not sure it would have worked. But not trying sure resulted in a lot of pain for her (don’t look up her pictures during lunch time).

If any CAM treatment can really cure cancer, she missed it, too. And she was desperate for anything to help her.

Wait — are you seriously claiming that the absence of evidence is evidence of absence, in general? Am I misreading you? I hope so ’cause otherwise you fail logic 101, which may suggest why I get the same creepy feeling from you as I do from the witch doctors.

Deductively, it’s absolutely the case that a non-determinate premise does not imply that the claim of syllogism is false; that’s not even the case when the premise is false.

Inductively and abductively, it’s a bit different since you have to look at the preponderance of evidence and meta-evidence — so there exists the special case that “absence of evidence after really, really, really looking hard is evidence of absence, at least until someone comes up with positive evidence”.

You meant the latter, right? And not nonsense in an academic tone, right? One really should be pedantic about one’s own phraseology when being pedantic vis-a-vis the phraseology of another.

Maxwell, to my knowledge (I took medicinal chemistry as my undergrad, and I’m a year out of my last drug development course, so I’m a bit rusty) that’s why a randomized clinical trial has a control group, to whom they give either a placebo or a known treatment that works (depending on the ethics involved in the study: ethically, you couldn’t give severe asthmatics a placebo treatment, for example – you could kill someone doing that… but giving people with a mild headache a placebo instead of the painkiller you’re studying is okay, assuming the patient knows there’s a chance they’ll get placebo and consents anyway).

The important thing is that the patients and the caregivers don’t know which patients are getting which treatments (hence the descriptor “double-blind”) – that way, there’s no bias in clinician reports.

If I recall correctly, patients are assigned a number, and the treatment for that number is prepared by different people (often in a different location) and then delivered to the caregivers. After the study is completed, the data is collected and only then do the caregivers find out who received which treatment.

Zilberberg then makes the âabsence of evidence vs evidence of absenceâ mistake â really and oversimplification of this concept to the point of being wrong. While it is true that the absence of evidence if not necessarily evidence of absence â it can be, depending upon how thoroughly you have looked. If I search my house for a specific item and donât find it, that is pretty good evidence that itâs not there. It is not âproofâ of absence, but it is evidence. With many of the modalities that Zilberberg admits she is personally dubious about there is evidence of absence of an effect. This evidence comes in two forms â all of the science that tells us the modalities are highly implausible, and often there is clinical evidence of lack of an effect. To pretend otherwise is dishonest â it is hiding from the facts out of political correctness.

It’s a reference to Douglas Adams’s radio series/five-part-trilogy/computer game/TV show/movie/etc “The Hitchhiker’s Guide to the Galaxy.” “A load of dingo’s kidneys” shows up on at least a couple of occasions to denote something which is completely ridiculous. First reference is, I believe, this:

The Babel fish is small, yellow, leechlike, and probably the oddest thing in the Universe. It feeds on brainwave energy received not from its own carrier but from those around it. It absorbs all unconscious mental frequencies from this brainwave energy to nourish itself with. It then excretes into the mind of its carrier a telepathic matrix formed by combining the conscious thought frequencies with nerve signals picked up from the speech centers of the brain which has supplied them. The practical upshot of all this is that if you stick a Babel fish in your ear you can instantly understand anything said to you in any form of language. The speech patterns you actually hear decode the brainwave matrix which has been fed into your mind by your Babel fish.
Now it is such a bizarrely improbable coincidence that anything so mind-bogglingly useful could have evolved purely by chance that some thinkers have chosen to see it as a final and clinching proof of the NON-existence of God.
The argument goes like this:
`I refuse to prove that I exist,’ says God, `for proof denies faith, and without faith I am nothing.’
`But,’ says Man, `The Babel fish is a dead giveaway, isn’t it? It could not have evolved by chance. It proves you exist, and so therefore, by your own arguments, you don’t. QED.’
`Oh dear,’ says God, `I hadn’t thought of that,’ and promptly disappears in a puff of logic.
`Oh, that was easy,’ says Man, and for an encore goes on to prove that black is white and gets himself killed on the next zebra crossing.
Most leading theologians claim that this argument is a load of dingo’s kidneys, but that didn’t stop Oolon Colluphid making a small fortune when he used it as the central theme of his best-selling book, “Well, That about Wraps It Up for God.”
Meanwhile, the poor Babel fish, by effectively removing all barriers to communication between different races and cultures, has caused more and bloodier wars than anything else in the history of creation.

Dr. Zilberberg apparently needs to be told that the simplest way to keep the hole you’re in from getting any deeper is to put down the shovel.

Wow!

Let’s start with the whole “allopathy” thing. “Allopathy” – no matter how it was meant by Hahneman – simply means “treatment by dissimilars” (as contrasted to homeopathy – “treatment with the same”). That means that any treatment modality other than homeopathy is “allopathy”. Even if Dr. Zilberberg wasn’t trying to be insulting, she was being terribly imprecise.

Her “expla-pology” about the “non-overlapping magisteria” (NOMA) of “CAM” and real medicine is revealing. What it reveals is that she is not aware of the implications of this concept, which revolve around the what the magisteria are (“magesterium” loosely meaning “school of thought” or “teachings”).

Since both real medicine and “CAM” claim to be groupings of effective treatments for human ailments, this cannot be the basis for the different (and thus non-overlapping) magisteria. Both real medicine and “CAM” claim to treat both body and mind (disregarding the erroneous duality), so that can’t be the difference. So, what is the difference?

So far as I can tell, the only difference in the “schools of thought” – again, based solely on what they claim to represent – between real medicine and “CAM” is that real medicine desires (but does not always attain) its treatments be supported by scientific data and demands (but does not always enforce) that treatments found – by scientific data – ineffective or unsafe be abandoned. It also strongly encourages (but does not always attain) deferrence for scientific data over tradition, anecdote and intuition.

“CAM”, in contrast, does not look for scientific data regarding its treatments and will ignore any data that conflict with its therapies, deferring instead to tradition (“Traditional” Chinese Medicine, accupuncture, herbal medicines, etc.), anecdotes and intuition. “CAM” also does not abandon treatments that have been shown to be ineffective, it merely changes the fairy-tale used to explain how they “work” (e.g. homeopathy after Avogadro).

Given these non-overlapping magisteria, it might be more accurate to refer to real medicine and “CAM” as “reality-based medicine” (RBM) and “fantasy-based medicine” (FBM), respectively.

I would like to propose that we straighten out a problem of terminology, so that discussion time is not taken up with semantic and etymological quibbles. The basic reason why some people who are not proponents of quackery use the term “allopathic” medicine is because they need a term which does not imply that everything people with M.D.s customarily do is science based. Orac, and I, are advocates for science based medicine but the whole point is, SBM needs advocates and, as Orac says in this very post, somewhere south of 100% of medicine as currently practiced by the most mainstream physicians is science based as of now.

So “scientific medicine” does not define Orac and his colleagues. It’s an aspiration, not a fact. “Western medicine” doesn’t work either, since as Orac is fond of pointing out, what they teach at Harvard Medical School is widely accepted nowadays in the North, South, East and everywhere else. The basic justification of the term “allopathic medicine” is not its original meaning, which is long forgotten anyway, but that accredited medical schools today are descended from what was called allopathic medicine back in the day.

I would propose that we use the sociological term “the medical institution,” which however it may sound to you is not pejorative, nor does it refer to a specific organized entity such as Harvard Medical School or Mt. Sinai Hospital. It refers to the entire complex of professions, formal organizations, practices and customs which make up the social “institution” of medicine as practiced by licensed M.D.s and their allied professions. Practices accepted by the medical institution include science based medicine, but also other practices which have just been around for a long time or are generally accepted without an adequate evidence base. We can call these Modalities Accepted by the Medical Institution, MAMIs. That way, we don’t have to say “allopathic,” and we can distinguish between SBM and medicine in general as it is actually practiced.

The problem with “the medical institution” is that woo is becoming institutionalized too. I sometimes use “mainstream medicine”, but that suffers from the same issue. We might consider “real medicine”, but that may be a tad too loaded. There’s not any really perfect term.

The basic justification of the term “allopathic medicine” is not its original meaning, which is long forgotten anyway, but that accredited medical schools today are descended from what was called allopathic medicine back in the day.

Except that the “allopaths” never called themselves that. It was a term of exclusion used by the homeopaths — and they applied it just as much to herbalists as to the medical doctors, and would in time apply it to the mesmerists and the chiropractors as well. It just doesn’t apply.

But Calli, the whole point is, the original etymology of the term isn’t really important. Many words we use today with a widely accepted meaning come from terms which originally meant something very different. That’s how language works over time. If people started dredging through the dictionary to reject every term that used to mean something else we’d be unable to communicate.

BTW, it works the other way too. The old English “mann” originally meant a human being of either sex. Using the term “Man” to refer to humanity was not originally sexist. It only started to appear sexist after the word “man” came to mean “male human.” This sort of quibbling over word origins is, frankly, inane. All that matters is what the words mean today.

Dr. Zilberberg: “What is coming through for me is that perhaps my call to equipoise was a little over the top, as I do not seem to be approaching the above CAM issues in a frequentist, but more in a Bayesian way (though I remain committed to equanimity).”

That’s easy for you to say.

Dr. Zilberberg should collaborate with Lionel Milgrom (famed exponent of “quantum” homeopathy) in a paper on the drawbacks of evidence-based medicine. Between them they should be able to come up with some linguistic doozies.

Let’s start with the whole “allopathy” thing. “Allopathy” – no matter how it was meant by Hahneman – simply means “treatment by dissimilars” (as contrasted to homeopathy – “treatment with the same”). That means that any treatment modality other than homeopathy is “allopathy”. Even if Dr. Zilberberg wasn’t trying to be insulting, she was being terribly imprecise.

Actually, even homeopathy is allopathy since you’re treating a symptom with a ball of sugar, dose of water or drop of alcohol. You can’t treat “fever” with “fever”; even the use of “fever-causing” substances ain’t, ’cause the substances aren’t there. You’re treating fever with a small ball of sugar that was once wet.

But Calli, the whole point is, the original etymology of the term isn’t really important. Many words we use today with a widely accepted meaning come from terms which originally meant something very different. That’s how language works over time. If people started dredging through the dictionary to reject every term that used to mean something else we’d be unable to communicate.

My favorite example is “hussy”, which derives from “housewife”. Now how’d that linguistic transformation happen?

Let me just jump in and say that it’s pretty sad to see proponents of science and medicine taking the offensive against someone who is (ostensibly) on *their team* over what (in my humble opinion) appears to be semantic differences.

The anti-science, non-evidence-based crowd must be sitting back and laughing their heads off at us today.

Congrats Orac. You may very well be on your way to winning the verbal battle and losing the war (for skeptical hearts and minds…)

Considering that most modalities under the “CAM” umbrella are themselves mutually exclusive and incompatible with each other (as well as SBM) in regards to the causes and treatment of disease, the NOMA gambit even less sense.

Here are a couple of thoughts:
1. My post “Furthering the discussion” starts out with an apology for setting a confrontational tone. Why do you not mention that in your post?
2. Why do you feel the need to spend an entire paragraph debunking the 5-20%, when I had already said that it is outdated? Does this really advance the debate?
3. Your point about doing RCTs whenever possible is valid. Some have advocated naturalistic pragmatic trials, but the issues with them are vast. And yes, while large prolonged cohort studies are quite expensive, so are randomized controlled trials. Can you imagine the number of patients that would have to be enrolled in a large pragmatic trial in order to smooth out the heterogeneities in the population and to have meaningful follow-up time? As an example, a 10,000 patient trial following patients for 5 years costs probably close to $100 million. Yes, RCTs would be great, but to make them useful, we need to start printing the money to pay for them.
4. You said: “Moreover, as I hope Dr. Zilberberg would agree, one characteristic of pseudoscientists is that they drill down on individual studies, demanding “just one study” that “proves” the point that an advocate of evidence-based medicine (EBM) and SBM is arguing. It’s not that easy. It takes a convergence of evidence from multiple studies, all leavened with a consideration of all sources of evidence, including basic science.” Yes, I agree. I believe I even went through how guidelines are developed in my post.
5. Allopathic terminology: At the risk of sounding snide, if you are so convinced of my ignorance on other more important topics, why do you doubt my ignorance of the nature of this term?
6. You said: “However, there is a strain of antivaccine thought that argues that vaccines are useless or that their benefits are hugely exaggerated”. Really? And you give my chickenpox quote as an argument for this? I certainly do not call a rational question being and “anti-vaxer”. Yes, I know you did not explicitly called me one, thanks.
7. You said: “this line of argument comes perilously close to Jenny McCarthy’s beloved “too many too soon” slogan”. OK, so by this logic I cannot state what is not known? Is it known? Do we have any long-term or multi-exposure data here? If yes, please, tell me where I can find it. Don’t weaken your argument by saying something is invalid because someone you don’t like has said it. Tell me why I am wrong, and I will gratefully advance my knowledge.
8. You said: “akin to someone expressing skepticism towards some aspect of evolution and thereby appearing to support creationism”. Really? Can you say more about this? I appear to support anti-vaccine movement because I am saying that I am not aware of evidence that presumably exists that answers the questions that I raised? On the contrary, if such evidence exists,I would be mot grateful for being pointed to it.
9. You said: “When that happens, a claim is being made that these are therapies, rather than exercises or modalities that make you feel good (or “gives you a sense of well-being,” as Dr. Zilberberg puts it). In that case, there is a claim for therapeutic effect that should be tested before physicians should be recommending it.” Thanks for clarifying. In his JAMA user’s guide to medical literature in 2000, Gordon Guyatt states that, because of heterogeneity in treatment effect, at the bedside n of 1 trials are at the top of the evidence pyramid (I blogged about it here: http://evimedgroup.blogspot.com/2010/09/clinical-decision-making-evidence-is.html). So, perhaps we could design some n of 1 trials to test massage as a therapeutic modality.
In general I do think that Western medicine and other modalities are used for completely different purposes, and should be kept separate as such. I know that these words could come back to bite me, as this is a very short-hand of what I really think. If you are really interested in what my views are, I am delighted to engage in a coherent and nuanced conversation.

I responded to your comments because I thought it might be only fair to clarify for you and your readers some of the mistaken impressions above. Hard as I try not to feel that this is exactly an ad hominem attack, I keep coming back to that. You accuse me of having no substance to my arguments and building straw men. I know I am in the minority on this site, but I dare ay that that is how I ma perceiving your posts.

I know, digging a hole. What a pity that for many of your readers this is a zero-sum game, where only you have to win. I am sorry, but that is not how I understand science. How disappointing that a sincere attempt to find common ground is resulting in such a categorical rebuff. Oh, well, it is still worth trying to bring us to a higher level of discussion.

Does anyone else feel somewhat insulted when an uncritical person tells them they’re only interested in ‘furthering the dialog?’

I’m interested in furthering the discussion, too. It’s why I pull no punches and am as critical as my layman’s understanding allows me to be. I don’t understand why I’m suddenly the bad guy for actually behaving like a skeptic.

You accuse me of having no substance to my arguments and building straw men.

I don’t have time to answer each of your points in depth because I have to run for a dinner function/fundraiser for our cancer center at 7 PM that will keep me occupied most of the evening. Maybe later tonight or tomorrow. In the meantime, I can’t help but point out that you seem to have difficulty distinguishing valid, albeit harsh, criticism of your statements, arguments, and language from attacks on you personally. It’s a common problem people have when their beliefs make up such a big part of their identity, but try to separate the two. Also, smart people sometimes make bad arguments and build straw men all the time, and they often don’t have malicious intent when they do it. They do, however, lack either the relevant arguments and logic skills to avoid such pitfalls. Being smart doesn’t always mean being able to argue effectively. Again, try to separate the two. I’ve had far worse things said about me and what I say, and I rarely take it personally. Heck, I wouldn’t even take it personally if you were to call me a “rabid” defender of vaccines, as you characterized some before.

In any case, if you’re going to delve into these debates with such gusto, particularly if you are going to do it using such heated rhetoric and referring to SBM (for example) as “arrogant” and “paternalistic” or throw around terms like “rabid” and misusing terms like “allopathic,” you really shouldn’t be surprised when you occasionally get some pushback. Seeing your blog, I’m really surprised that you haven’t had some fairly harsh criticism before, which is why I suggest that you also really need to develop a lot thicker skin than you appear to have. That, and learn about the tactics of pseudoscientists like creationists and antivaxers, so that you don’t use arguments and rhetoric that lead people to mistake you for one.

I know you won’t believe it, but that’s some friendly advice. It’ll help you enormously if you wish to continue blogging about science and medicine. Please take it to heart.

In general I do think that Western medicine and other modalities are used for completely different purposes, and should be kept separate as such.

“Western” medicine? Then you should like both the varicella and DTaP vaccines because they were both developed in Japan. (note, this is to point out that “western” is just about as annoying as “allopathy”, because while that latter gives credence to a 19th century quack, the former gives credence to the Flat Earth Society).

And I still can’t figure out why anyone would not want to avoid over two weeks of a miserable child covered in itchy pox, with the added “benefit” of being eligible for shingles later in life…. as opposed to getting a vaccine that has been around for about twenty years. I understand it as much as I understand Munchhausen Syndrome by Proxy (which I don’t).

Can you tell me exactly what advantage getting varicella has over the vaccine? And what to do with immune compromised kids in a school with a varicella outbreak? Since the 1994 outbreak in my kid’s school lasted well over a month (saved by winter break!), is the kid who can be severely injured supposed to stay home?

OK, so by this logic I cannot state what is not known? Is it known? Do we have any long-term or multi-exposure data here?

Knock yourself out (you might want to click on the other links at the top of that list). Oh, and you might want to talk to these guys. They might be able to help you.

I am still baffled why Jenny McCarthy goes on about the MMR vaccine. Her son had his seizures almost a year after getting it. Plus, how long term is “long term”? The MMR used in the USA is almost forty years old. How long did you want to study it?

And really, don’t the large scale epidemiological studies done in Denmark, UK, USA and elsewhere qualify as “multi-exposure”?

Chukwuma Onyeije, M.D.: “Let me just jump in and say that it’s pretty sad to see proponents of science and medicine taking the offensive against someone who is (ostensibly) on *their team* over what (in my humble opinion) appears to be semantic differences.

The anti-science, non-evidence-based crowd must be sitting back and laughing their heads off at us today.”

They may well be, seeing as alties view spirited internal debate as a sign of weakness, much as mainstream medicine’s revising views to accomodate new and better evidence is considered a failing (which reflects the general stagnation of woo and refusal to reject failed therapies).

Congrats Orac. You may very well be on your way to winning the verbal battle and losing the war (for skeptical hearts and minds…”

This has the air of concern trolling, since the “semantic differences” on Dr. Zilberberg’s side which include contemptuous and derogatory language (i.e. referring to “rabid” pro-vaccine advocates) are going unchallenged by Dr. Onyeije.

Rather than worrying about who is a meanie (or the bigger meanie) I consider who can back up their contentions with solid evidence.

I had chickenpox when I was 18, right in the middle of my first year of university. I was out of commission (and MISERABLE) for a full week. You better believe I wish I’d been vaccinated! It ought to be at least *offered* at all elementary schools.

But Calli, the whole point is, the original etymology of the term isn’t really important. Many words we use today with a widely accepted meaning come from terms which originally meant something very different. That’s how language works over time. If people started dredging through the dictionary to reject every term that used to mean something else we’d be unable to communicate.

It’s not been very long since the word was used strictly to mean “non-homeopath”. There are homeopaths today who still use the term in its original sense, so I don’t think it’s fair to compare it to words like “man” which shifted its meaning before English even acquired its modern form.

But yes, let’s look at the modern usage! Predominantly, the term “allopathic” is used by practitioners of alternative medicine (ironically, including naturopaths, chiropractors, acupuncturists, etc) to refer dismissively to conventional medicine. It is seldom meant kindly. That a few people have adopted it unaware of its normal usage should not encourage the rest of us to adopt it. I refuse to accept an insulting term just because a minority of people do not use it in a derogatory way. My husband’s grandmother uses the infamous n-word and doesn’t mean anything by it. (Indeed, the term did not used to be considered impolite.) This would be no excuse for my using it now, merely because she doesn’t mean anything by it.

sort of quibbling over word origins is, frankly, inane. All that matters is what the words mean today.

Insane? You’re talking to an English major. I find etymology fascinating. But you are correct that the modern usage is important, which is why I still refuse to use “allopathic” to refer to conventional medicine. It is part of the linguistic toolbox that keeps the false dichotomy alive, and I will not submit to that. I will just barely accept “conventional” versus “alternative”, on the basis that I haven’t found anything better.

I hate “tap click”. I wish I was allowed to disable it on this PC. (I’m on a work computer.) I submitted before I was done.

Furthermore, the word “allopathic” is a mere 200 years old. English has not shifted very much in that time, and you can see that in reviewing modern dictionary definitions of the term, which retain the original meaning. They may add a few more, to reflect its narrowing to exclude some non-homeopathic practices. For instance, Wiktionary notes that in the US, UK, and EU, it is used “principally to distinguish it from homeopathy”, and in the US, “sometimes . . .to distinguish MDs from DOs (osteopathic physicians), usually in discussions of medical education.” In India, it notes, it is “used principally to distinguish “Western medicine” from Ayurveda, especially when comparing treatments and drugs.”

So the term remains principally a means for non-standard medical practitioners to distinguish themselves from the mainstream, by giving the mainstream a label. They do this largely because the mainstream has no self-descriptor of this sort.

I will just barely accept “conventional” versus “alternative”, on the basis that I haven’t found anything better.

And both are better than “western” medicine. Growing up with a father who loved anything Asian (including being stationed in Korea a couple of times, both without family), and having a daughter who has absorbed Japanese and Korean culture: I find the implication that “eastern” has special qualities that are not related to the modern world abhorrent.

Especially with all the very processed and packaged food we bring home from the Asian and Pacific grocery store (though happily we found Dutch chocoladehagel on the Indonesian/Malaysian aisle). Yes, I have a wok and know how to use it.

I do really appreciate the real research that is done in Asia. If one has been paying attention, many of the Nobel laureates lately have Asian names. So please, stop the provincial thinking that divides valid science research with an arbitrary geographic line.

2. Why do you feel the need to spend an entire paragraph debunking the 5-20%, when I had already said that it is outdated? Does this really advance the debate?

Outdated? It was never “dated”! That number was a canard taken from a survey of a few GPs many years ago, quoted by some asshole bureaucrat, which has been misused and abused by various med bashers and alt-med nuts more times than I could count. That’s why it needed to be given a little Respectful Insolence ™.The fact that you reference it greatly harms your credibility.
What would advance the debate would be to bury this bullshit statistic with a stake through its heart.

Orac, found this article that comments about ‘tone’, in a very scientific setting.
I read your posts regularly but I sometimes wonder: are you just cheering for your own side? or do you really want to change opinions of people who are mistaken?

Some folks you can’t change; but sometimes I think your approach is needlessly confrontational, when you could do more harm than good.

Humans are not all easily-understood physiology, but we are also not all spirit and mystery. We are in fact both.

No, we aren’t. (And no one has claimed the former, so knock it off with the strawmen.) To say that we are “mystery” doesn’t even make sense. “Spirit” is a scientifically meaningless term.

In general I do think that Western medicine [sic] and other modalities are used for completely different purposes, and should be kept separate as such.

What other modalities, and what purposes?

Perhaps, Dr. Nongeneralization, rather than continuing to make these broad assertions you could discuss a single condition or a particular CAM modality used in the treatment of a specific condition. That might help in moving the discussion forward.

Same with healing crystals, reiki and prayer. So, if a person wants to engage in these activities, and they are perfectly safe physically, be my guest.

Aside from the issues people have raised already, reality has so little value for you?

***

Some folks you can’t change; but sometimes I think your approach is needlessly confrontational, when you could do more harm than good.

Similar to the topic of “allopathy,” I find the act of calling science “Western” inherently offensive: It’s a form of casual racism.

There’s nothing “Western” about science, aside from meaningless historical accident. Race and nationality had nothing to do with it. Science is what we do to protect ourselves from self-deception. Self-deception is a universal human flaw. It is NOT exclusive to white people.

Anti-Asian: “Asians are all dumb-dumb heads who can’t handle the statistics and complex interactions of science, but that’s okay, because the gods/aliens/Atlanteans/transcendent gurus/whatever compensated for their inherent stupidity by giving them magical knowledge that’s obviously true. They can’t handle science, therefore they get compensated with magic.”

I think I have to agree with Chris that calling it “Western” is actually worse than “allopathic” — both have strong vulgar and offensive connotations, but “Western” goes a step further and goes for racism and jingoism. Bronze Dog hits the nail on the head — it’s a term that can be racist in both directions, so I guess it’s at least egalitarian in that everybody gets insulted.

BTW, cervantes, I apologize if my tone above @ 35 and 36 is too harsh. I’m looking back on it now, and it’s sounding more harsh than I was thinking last night. I’m just a bit of a word geek at times, and last night I was pretty fried. You make a good point that the modern usage is more important than the original usage; I just don’t think the modern usage has really drifted all that much. I feel that we’re playing into the alties’ hands if we call our own position “allopathy”, a term which is neither accurate nor flattering.

RE: “Let them laugh. Science will not progress if scientists can not criticize each other for fear of embarrassing themselves in front of ignorant charlatans.

If we have to stop pointing out the flaws that other scientists make, we might as well give up and go home.”

Science (and medicine) can and does progress when individuals with disagreements have a sense of civility and decorum vis-a-vis differences in opinion. Believe it or not; in my “day-job” as a physician I actually have differences in management and opinion with my colleagues. If I were to use the techniques I see utilized here to resolve these differences I suspect I would rapidly lose the respect of my colleagues and our patients.

Unfortunately, many of the “ignorant charlatans” that we may be embarrasing ourselves in front of are *also* people who (one day) will come to us in search of a resolution to painful or difficult situations.

Mark me down as one who wants to advance the cause of science while (…. wait for it) maintaining a civil tone. I don’t think we have the luxury of alienating professional contacts and potential clients by engaging in slash and burn debate tactics.

If I were to use the techniques I see utilized here to resolve these differences I suspect I would rapidly lose the respect of my colleagues and our patients.

Different contexts call for different approaches. Of course the general tone of RI would be inappropriate for most work environments. Although focused on scientific skepticism, this blog allows for a bit of snark and sarcasm. The same topic would be treated with a less snarky, more professional tone, overall, at Orac’s “friend’s” blog.

True, this ain’t Uesnet, but it isn’t a corporate board room or the Queen’s audience chamber, either.

Gee. Thanks for the new vocab word. Seriously. All this time I’ve considered the recognition and balancing of someone’s (alternative) perspective with my dogmatic science-based imperatives to be “patient care”.

I think I’m going to stick with my traditional moniker; but the next time I engage in this activity you can bet I’ll be thinking about the fact that I’m “concern trolling”.

Okay, you’re naive, Chukwuma: There is no single magical strategy that will convince everyone. For people like me, excess civility is counterproductive.

It was sharp-tongued people like Orac who got me out of being a shruggie. Their passion is what snapped me into paying attention. If you’re too calm, people like me sometimes end up perceiving the issue as unimportant, trivial, or pedantic: If you don’t get occasionally worked up about the issue, “obviously” there’s no need for me to pay closer attention.

And with medicine, lives are on the line. If you don’t get angry when dealing with someone you think is endangering people’s lives, something is wrong with you.

@Bronze Dog.
Um. Yeah. Sure.
Interesting interplay in your last post….
“There is no single magical strategy that will convince everyone.” and “If you don’t get angry when dealing with someone you think is endangering people’s lives, something is wrong with you.”

Points taken. Next time I’ve got someone standing on a (metaphorical) ledge and ready to jump I’ll be sure to pull out my most bilious invectives to coax them down. Likewise for the person who’s actions put others at risk. Yeah.

I’m aware that there are different techniques to get a point across and I’m no stranger to snark or sarcasm as a method to make a point appreciated. I’m actually a fan of such tools if they are right for the job…

I assume I’m also free to criticize a particular method of conversation if I feel it’s not helpful. No?

@Bronze Dog- But at the same time your rigid fundamentalist approach to everything can blind you and cause you made grave mistakes through sheer arrogance and, dare I say, ignorance. Not to mention suck the joy right out of your life.

I read her posts and they aren’t a “broadside”, only a mild suggestion to be less arrogant and sure of the virtues of science-based medicine.
I’ve found myself that sometimes alternative medicine sites say true things that aren’t on Medline.
Medicine is in a state where people can still make accurate observations based on their clinical experience, or even good observers can notice things in their daily lives that are true but not well researched.
When I found this out, I was dazed by cognitive dissonance. I had supposed that the SBM was a lot more complete than it was, and that alternative medicine books about “finding your hidden food sensitivities”, etc. had no more sense than the same weight of gravel.
The truth is more nuanced. Alternative medicine is a combination of true but not well researched or understood things like hidden food sensitivities, and placebo-based treatments like homeopathy. And science-based medicine is less complete than many of its practitioners think.
Many of the attacks on alternative medicine are a kind of equivocation. Agreed that there are many treatments that have got to be worthless, like homeopathy. But there’s a middle ground that’s not really part of SBM – like food sensitivities – but has long been part of alternative medicine. This middle ground gets discredited along with the rest of it, because criticisms of the easy targets like homeopathy, serve to discredit alternative medicine in general.

But there’s a middle ground that’s not really part of SBM – like food sensitivities – but has long been part of alternative medicine.

Wait. Why are “food sensitivities” not part of SBM? Food allergies, lactose intolerance, celiac are all within the scope of SBM. What specific claims does alt-med make that differ from SBM, and what evidence do they have to support those claims?

Points taken. Next time I’ve got someone standing on a (metaphorical) ledge and ready to jump I’ll be sure to pull out my most bilious invectives to coax them down. Likewise for the person who’s actions put others at risk. Yeah.

You seem to be missing my point: Different people respond to different approaches.

I don’t pretend that brutal honesty and snark works for everyone, just like I don’t try to pretend stoic civility works for everyone. I try to adjust according to the audience and the situation. I favor frankness and snark as a default tone primarily because that’s what I respond to. If, however, I think someone will respond to civility, I can bite my tongue stick to the facts.

Personally, I’d prefer it if we didn’t have people taking sides based on tone: Different people have different styles. If I find a stoic, civil person, that’s wonderful: I can refer people to their work if I think they’ll respond to it. I recently referred a ban-seeking troll on Skeptico to an excellent Qualia Soup video where he calmly, and in simple language, explains what open-mindedness really means.

Frankly, I think people complaining about tone is potentially counter-productive: It gives closed-minded people an excuse to be thin-skinned. Instead of addressing the substance of an argument, they can complain about tone as a distraction from the core issue. I’ve seen it used countless times to perform style over substance fallacies.

Different people have different specialties that work under different circumstances. We can’t all be perfectly generalized.

DrWonderful:

@Bronze Dog- But at the same time your rigid fundamentalist approach to everything can blind you and cause you made grave mistakes through sheer arrogance and, dare I say, ignorance. Not to mention suck the joy right out of your life.

Where did you get the idea I was being rigid? If you look at the previous part of this post, you’ll see that I’m making an argument for community flexibility: Different people have different strengths. We should have enough diversity that we can cover each other’s weaknesses. My problem with concern trolls isn’t with civility. It’s that they too easily seem to favor crippling over-specialization in “civility.”

Excess politeness can lend false credibility to absurd positions. It can also create a perception that the issue isn’t worth investing any emotion or effort. I hate to say it, but I’ve run into my share of concern trolls who seem to deny that anyone is capable of my sort of emotional reaction, like I’m lying or that I can’t exist: Being passionate while remaining concerned about the substance of the arguments presented alongside the invective.

Oh, and please don’t speculate about my personal life. I’m quite happy overall, and being snarky and humorous about the bad things going on in the world is one way I deal with it. I saw a bunch of skeptics express their anger in a manner that ended up being constructive (convincing me to pay attention, learn, and ultimately agree with them) so I try it myself.

Alternative medicine is a combination of true but not well researched or understood things like hidden food sensitivities, and placebo-based treatments like homeopathy.

If it’s not been properly researched or understood, then you don’t know that it’s true. Might SOME of the lunacy in sCAM about food sensitivities be true? Potentially. But certainly not to the extent claimed. But as soon as it’s shown to be true, it ceases to be sCAM and becomes real medicine.

In other words, there is no middle ground. If it’s supported by science, then it’s real medicine. If it’s not supported by science, then it’s not valid – even if later shown to be true, until that point it’s useless and meaningless.

When I was in thrall to magical-thinking, it was confirmation bias that made me think that all the CAM crap I spent a fortune on was working.

I surely would have seen Orac and SBM as “arrogant” and “snowman melters” who were obviously “bitter unhappy people”.

Well, turns out it was I who was bitter and deluded in my little fear-based reality. It was an actual illness that was resolved with actual medicine that turned me around. My vitriolic stance towards “allopathic, western” medicine were based on the fact that deep down inside, I feared that there was no magic. That the nostrums that I gobbled down in my worried well state were really not doing anything became obvious the second I tried them against an real illness.

As for being unhappy or joyless as a rationalist? Accepting reality provided the liberation from fear I always sought as a magical-thinker. Look at a Hubble image and try not to be moved.

So for me it’s tone wars be damned! All the politeness or vitriol in the world didn’t amount to a hill of beans in my transformation. Looking horrible pain in the eye did. Once on the other side, I gravitated to where the party was.

Dr. Onyeije: “Unfortunately, many of the “ignorant charlatans” that we may be embarrasing ourselves in front of are *also* people who (one day) will come to us in search of a resolution to painful or difficult situations.”

If you took the time to read other articles and commentary here you’d find that people (including potential patients) who are unsure or confused about healthcare options and trying to get valid information are answered civilly and guided to reliable sources.

On the other hand, strident woo-promoters and “Western” medicine-bashers are often countered in a less respectful, even “insolent” tone.

There’s a difference between ridiculing Jenny McCarthy’s antivax nonsense and providing helpful information to a parent who’s uncertain about the benefits of vaccination.

Are we clear here?

Dr. Zilberberg (who is poorly qualified to complain about “tone”) appears to be using the “you’re a meanie” defense to distract attention from the substance of what she’s saying.

Dr. Onyeije: “I assume I’m also free to criticize a particular method of conversation if I feel it’s not helpful. No?”

Of course. It would be helpful, though, if you took on “particular method(s) of conversation” as they apply to both sides in this situation, and even commented on the substance of what’s being said.

Bronze Dog: “You seem to be missing my point: Different people respond to different approaches.”

To be fair, there have been studies showing that “third party observers of arguments perceive greater levels of aggression and less credibility of parties who engage in even ‘light’ aggressive tactics.” On the other hand, ridicule can be effective within an in-group. Now if you already trust that Orac is reasonable and has his facts straight, then his snark comes off as passion. However, based on the research that has been done, I can see outsiders viewing him with suspicion because of his barbs (and I say that as someone who is entertained by Orac’s sarcastic brand of humor).

On the bright side, Orac generally does hold to the rule, “If you’re going to be sarcastic, you’d better have all your ducks in a row,” which puts him ahead of plenty of other wielders of ridicule.

About tone in scientific debates: When I was in college there was a conference on the subject of our engineering department in the city. Many of us students were recruited to run the slide projectors for the talks (our reward was a table at the final luncheon). While I was running the projector in one room shouts could be heard from the next room. I learned later that it was from a local engineering supervisor from one of our largest employers who was calling out the presenter on something. It was the talked about all day.

Fast forward three years later, and guess who is my new supervisor! That very same snarky cantankerous guy! He was the best supervisor I ever worked with (I was actually sent to him from my previous supervisor where the hate was mutual). I learned lots, and got lots of support for my work.

One of the biggest problems in the “be civil” debate comes down to the fact that (in)civility is in the eye of the beholder. Too often, it seems that “uncivil” means “didn’t sufficiently accept the validity of my claim.” IOW, if you don’t respond by blowing sufficient fluff up their skirt, and praise them for acknowledging the stuff that you agree with, then you are being mean.

It’s meaningless drivel. There isn’t enough room in life to preface every statement with “You are right when you say these things, but I disagree with your postulate about this other part.”*** Get to the point, and don’t worry about getting your bloody feelings hurt. If you think it’s wrong, say it’s wrong. If you don’t think you were wrong, explain why.

***Actually, that is even unnecessarily verbose – it is considered rude to say “you are wrong about this other part,” even when that is something is a statement of fact. I have related in places where I (and others) have been accused of “personal attacks” because we had the audacity to correct someone’s factually incorrect statement. Apparently, we did not give enough respectful consideration of the incorrect statemnet. This is the world you walk in when you make it about civility. Everyone’s version of what is civil varies. Personally, I have found none of this exchange to be uncivil at all, but that is me. The discussion has always focused on the argument, and not gotten personal. What else could you ask for?

So good, it had to be repeated, just for the woo-heads (or is just one guy and his sock puppets?) who are now swarming this site:

When I was in thrall to magical-thinking, it was confirmation bias that made me think that all the CAM crap I spent a fortune on was working.

I surely would have seen Orac and SBM as “arrogant” and “snowman melters” who were obviously “bitter unhappy people”.

Well, turns out it was I who was bitter and deluded in my little fear-based reality. It was an actual illness that was resolved with actual medicine that turned me around. My vitriolic stance towards “allopathic, western” medicine were based on the fact that deep down inside, I feared that there was no magic. That the nostrums that I gobbled down in my worried well state were really not doing anything became obvious the second I tried them against a real illness.

As for being unhappy or joyless as a rationalist? Accepting reality provided the liberation from fear I always sought as a magical-thinker. Look at a Hubble image and try not to be moved.

So for me it’s tone wars be damned! All the politeness or vitriol in the world didn’t amount to a hill of beans in my transformation. Looking horrible pain in the eye did. Once on the other side, I gravitated to where the party was.

Some commentors have brought up the aspect that studoes show that snark and sarcasm are not as effective on the whole in swaying som$eone’s mind. I am wondering, what do studies say about the strategy of whining like a spoiled kindergartener?

Dr. Zilberberg writes “Hard as I try not to feel that this is exactly an ad hominem attack, I keep coming back to that. You accuse me of having no substance to my arguments and building straw men. I know I am in the minority on this site, but I dare ay that that is how I ma perceiving your posts.”

This betrays a misunderstanding of what “ad hominem” means. It is not merely a fancy Latin term for being rude or insulting. Rather, it refers to the fallacy of attempting to refute an argument by criticizing the person making the argument, rather than the argument itself. So while it may be unwelcome to hear somebody state that your argument is lacking in substance or a straw man, it cannot be ad hominem because it is a criticism of the argument, not the person.

However, I do think that Orac’s identification of the word “allopathic” with purveyors of CAM is unfair. Orac to the contrary, over the years I have frequently heard the term used by physicians and pharmacologists to identify their own approach and to distinguish it from homeopathy. One might wish that legitimate physicians and pharmacologists had been less willing to adopt a word coined by homeopaths, but it unreasonable to expect physicians who are not familiar with its origin or its usage by CAM advocates to be aware of its negative connotation.

If acupuncture seems to help my neighbor with her subjective symptoms of menopause, so be it, I am happy for her, even if I do not fully understand how it works.

I’m curious here: would Dr. Zilberberg recommend a placebo to her patients without making it clear that it’s placebo on the theory that little fibs are justified if they make someone feel better? If so, I wonder if the charge of ‘paternalism’ — or maybe ‘mommy-ism’ — might apply.

If she wouldn’t recommend a placebo to her own patients for ethical reasons, then why wouldn’t the same ethical reasons compel her to argue against other people doing so?

Humans are not all easily-understood physiology, but we are also not all spirit and mystery. We are in fact both.

Somehow I suspect that this statement is connected to this statement:

In general I do think that Western medicine and other modalities are used for completely different purposes, and should be kept separate as such.

Does “Western medicine” deal with the body — and those “other modalities” (CAM) deal then with what could be termed the “spiritual dimension?” Would atheism, say, preclude a physician from appreciating the importance of this? I’m just trying to figure out how deep the waters are.

To be fair, there have been studies showing that “third party observers of arguments perceive greater levels of aggression and less credibility of parties who engage in even ‘light’ aggressive tactics.” On the other hand, ridicule can be effective within an in-group. Now if you already trust that Orac is reasonable and has his facts straight, then his snark comes off as passion.

1. I wasn’t in the in-group when I first started hearing skeptical takes on alternative medicine or other pseudoscience. This is about how I ended up becoming a skeptic.

2. Yes, there are lots of people for whom civility works. I don’t need to look at detailed studies to know and agree with that. I may be an outlier, but brutal honesty alongside consistent good arguments is one (1) legitimate tactic when you’re dealing with someone like me. My emotional responses may not conform to the majority of human beings, but if there is a niche, however small, of people like me, we need some people to cover that niche. We also need stoic polite people. There is no single solution, so we need to work from multiple angles.

3. Often, my harshest snark falls orders of magnitude short of my typical opponents’ nastiness. In many cases, it seems to me that different people are blind to their own tone. I at least try to conscious of my tone. I’ve seen many sorts of woos who can make all sorts of horrifying statements because their culture makes them so casually without thinking about it, like the racism I mentioned earlier.

Yes, there are lots of people for whom civility works. I don’t need to look at detailed studies to know and agree with that. I may be an outlier, but brutal honesty alongside consistent good arguments is one (1) legitimate tactic when you’re dealing with someone like me.

Thing is, incivility tends to be a red flag that an argument isn’t good because it’s often used to distract from an argument’s weaknesses. It may be that you are simply more cautious than most about using incivility as a heuristic of argument quality, especially if other signs of good argument are present. It may also be that you do use that heuristic against those whom you have not yet deemed trustworthy, and in that case, you really aren’t an outlier at all. Bear in mind that (1) you are one anecdote, and (2) I really don’t know the circumstances under which you first read Orac’s work, so how well you fit with the norm is unclear.

People should listen to J. J. Ramsey! It’s his grasp of the rhetorical arts that’s brought him to the point of emailing PZ begging to be released from the Pharyngula dungeon, and his commitment to evidence and honesty was clearly demonstrated in the Tom Johnson affair.

I think Orac is a bit harsh on the allopathic terminology. I only learnt about the associations that some applied when I used it myself on this site, and I thought it was quite rude the way that the commentator who responded to me assumed that I already knew about it and was deliberately insulting doctors. It’s not a nasty-sounding word in and of itself, and words only have the context we grant to them. I think the best response to a word that is meant as a mild insult is to use it left, right and centre favourably – so I approve of that TV show titled “Queer eye for a straight guy”. To give another example, as a New Zealander, I often call myself a Kiwi, like my fellow citizens. Now if you think about the kiwi bird, that’s an insulting comparison, it’s nocturnal, timid, short-sighted, flightless and endangered. But anyone trying to insult a NZer by calling us Kiwis would have to be entirely reliant on context, Kiwi is a positive word when used for NZers because we use it about ourselves.

As for Western medicine, I use “Western” to mean that group of economies and cultures that encompasses North America, Europe, Japan, Australia and NZ all the time, at least with a round earth we know that every single country in the West is to the west of at least one country that’s not in it. So “Western” is 50% right, which is better than any other term I’ve heard (“Third World”?, so only coming third in the human race, “Developing nations?”, so Europe and the US have reached the pinnacle of human development, aye? “North vs South”? No Kiwi is going to use “north” to mean rich country (I remember my environmental economics lecturer at university, it was his first year in NZ and he had come from Vancouver, he started introducing a model based on a rich North and a poor South, then suddenly turned around and saw all of us grinning at him, and sighed and changed his terminology.)

It’s good that you’ve figured it out now. Someone coming new into an ongoing discussion like this could easily hear or read terms being exchanged and repeat them without being aware of their background or connotations.

A trained medical doctor like Dr Zilberberg should have been aware of this usage, though. I would be extremely surprised if she had a course in Introductory Allopathic Medicine as part of her medical school training.

And, as you mentioned, there are some groups that use terms among themselves that would be considered pejorative if used by someone else to refer to them.

People should listen to J. J. Ramsey! It’s his grasp of the rhetorical arts that’s brought him to the point of emailing PZ begging to be released from the Pharyngula dungeon

You really do not want to bring this up. I come out like a jerk, but PZ Myers comes out pretty much a liar, even to the point of claiming that he never hinted that I “made extremely inappropriate comments about my under-age daughter’s sex life,” even though in the post where he made that false accusation on the old Richard Dawkins forums, he referred to an earlier post on the forums that mentioned me by name.

Now Bronze Dog and I were disagreeing, but we were disagreeing like adults, and then you come in with this red herring of yours. If you want to discuss the actual evidence on the effectiveness of ridicule, feel free.

I obviously did. Your fixation on PZ, Ophelia Benson (banned from Butterflies & Wheels, too? where else?), and others is neither healthy nor productive. This bitter agenda has crippled your judgment and led you to some terrible behavior. It’s astonishing that you think you’re in a position to lecture to anyone here on effective internet self-presentation.

… for protesting that she was using the stoning of a girl in an illegitimate emotional appeal to distract from the weaknesses in what she quoted from her own book. This, by the way, is the same person who casually described Mooney and Kirshenbaum’s views as “fascism” (her word choice!) and compared them to the Nazi policy of Gleichschaltung.

SC (Salty Current): “It’s astonishing that you think you’re in a position to lecture to anyone here on effective internet self-presentation.”

I was following cited literature, while you offered irrelevant ad hominems about me being banned from a couple blogs whose authors have a habit of getting unhinged. If you actually have something to offer besides personal attacks, please do so.

Another reason I and some others are skeptical about the tone argument is that it’s often a tool by the powerful to silence complaints. If you sound angry about oppression, you’re told that you need to calm down and state your complaints politely before anyone will take them seriously. If you follow that advice, you are then dismissed, with the comment that clearly this isn’t important because you aren’t shouting about it.

(Un)surprisingly often, the “calm down and then we’ll take you seriously” comes from people who are encouraged to shout themselves, and who listen to, or broadcast, things like Rush Limbaugh, programming that doesn’t even attempt to provide reasoned arguments in a calm tone of voice.

We’re allowed to be loud and angry about the results of a football game, but it’s suddenly “inappropriate” or worse to do so about discrimination in the NFL, extortion of tax money by team owners, or college sports covering up sexual assault.

I’m sure your “which puts him ahead of plenty of other wielders of ridicule” wasn’t an allusion to gnu atheists at all. (And of course your linking in response to a long rant about him on a blog that consists largely of long rants about outspoken atheists dispels that notion.)

… for protesting…

So you are banned from there as well. Metamagician and the Hellfire Club? Why Evolution is True? I’m not sure, but I suspect there are others. Even if you’re not banned from the blogs involved in these debates, you’re widely regarded as a tedious, time-sucking annoyance with an agenda. Orac, in contrast, is a successful communicator. Even for those who would see this purely in terms of short-term strategy and be interested in your links (of which I’m not one, having dedicated years of my life to studying the dynamics of real social movements), your interpretation of their applicability in this or any other specific context should carry no weight. In terms of putting ideas about persuasion into action you’ve shown yourself to be a miserable failure, and there’s no reason for anyone to take you seriously. Rather than criticizing others, you should be looking carefully at what you’re doing wrong.

[I’ll let the obsessive have the last word. I don’t want to participate in feeding Ramsey and hijacking Orac’s thread with this ridiculous tone nonsense. Apologies to Orac.]

[I’ll let the obsessive have the last word. I don’t want to participate in feeding Ramsey and hijacking Orac’s thread with this ridiculous tone nonsense.]

There’s some heavy irony. The issue of tone was brought up in the blog post itself, so contributing to a discussion on that matter is hardly hijacking. Meanwhile, even though you claim to have “dedicated years of [your] life to studying the dynamics of real social movements,” you chose to be petty, dredge up irrelevances, be an accessory to slander, and speculate on where I have and haven’t been banned, rather than actually contributing knowledge of your studies pertaining to the tone issue.

squirrelelite : And, as you mentioned, there are some groups that use terms among themselves that would be considered pejorative if used by someone else to refer to them.

Uh, I didn’t mention that, and if I did imply such a thing it was entirely a result of bad writing skills on my part, for which I apologise. I mentioned, specifically, the case of NZers calling themselves Kiwi, and being quite happy for others to call them Kiwis. I said that if anyone tried to insult NZers by calling us Kiwis, they’d be entirely reliant on context for effect. The word itself, as heard by NZers, not just as used by NZers, is not pejorative, despite that one can make a logical argument that it should be pejorative.
Of course, the group described by an insulting word are the natural ones to take the lead in turning the word into a positive one. From experience, it’s a nice way of annoying the people who are trying to insult you.

“…some people who are not proponents of quackery use the term ‘allopathic’ medicine is because they need a term which does not imply that everything people with M.D.s customarily do is science based.”

May I propose the term “reality-based medicine” (as contrasted to “fantasy-based medicine”) as a suitable alternative?

What most people consider “real” medicine may not always have solid science behind it (we still don’t know how inhaled anesthetics work, not to mention a goodly number of the psychotropic medications), but it is based in reality since it relies on replicated observations of efficacy and poses mechanisms of action that are based on scientifically supported principles of anatomy and physiology.

Modalities such as homeopathy, chiropractic (for anything other than musculoskeletal back pain), much of naturopathy (some herbs have very real effects, just not always the ones that the naturopaths claim) have guiding principles and precepts that are clearly fantasy-based (e.g. the “memory of water”, “spinal subluxations” as the cause of all disease, the benevolence of Nature). Other “alternative” modalities – such as “crystal healing”, “energy field manipulation”, intercessory prayer, etc. – are also (and obviously) fantasy-based.

By dividing medical interventions (and magisteria, if you like) into reality-based and fantasy-based, we get to the heart of the matter – not whether patients “feel better” or like the therapy, but whether there is any reason to believe that the “effects” claimed are real.

Granted, some of what we now think of as reality-based medicine will at some time in the future be found to be incorrect. This is how reality-based medicine works – it looks for data to support or refute the interventions and principles it uses and then eliminates those that fail the test.

Fantasy-based medicine, on the other hand, doesn’t reject failed therapies – it simply changes the fantasy they are based on. Thus, homeopathy went from extreme dilution to “memory of water” and vague, unspecified (and unsupported) “quantum effects” when it was discovered (after Avogadro) that homeopathic dilutions were unlikely to contain even a single molecule of the active ingredient.

This is not to say that some therapies currently in fantasy-based medicine don’t actually work – but, when they have been shown to work, they will automatically become reality-based. Likewise, once a reality-based therapy is shown to not work, it may be adopted by the fantasy-based practitioners. In fact, many of the current fantasy-based treatment modalities were once generally thought to be effective until they were shown to be ineffective.

Let’s not forget, either, that some fantasy-based treatments are effective, but are either less effective or less safe (or both) than current reality-based treatments. Also, there are some fantasy-based treatments (e.g. chelation for coronary artery disease) that are effective, but not for the disorder fantasy-based medicine uses them for (i.e. chelation is effective for lead poisoning, but not for coronary artery disease).

If you are speaking of a term corresponding to “everything people with M.D.s customarily do” even if it isn’t science-based, why not just call it “conventional medicine”? That’s easily understood, and allow one to distinguish between conventional medicine that is science-based (and thus effective) and conventional medicine that is the result of what happens when one shortchanges or bypasses the science (e.g. hormone replacement therapy).

“If you are speaking of a term corresponding to ‘everything people with M.D.s customarily do’ even if it isn’t science-based, why not just call it ‘conventional medicine’?”

Two reasons:

[1] “Conventional” is also used as a pejorative, implying that the practitioner is resistant to new ideas.

[2] These days, the set of “everything people with MD’s customarily do” includes a growing number of fanatasy-based treatments and recommendations. My own internist, who is as “conventional” a practitioner as can be, has made a number of dietary recommendations that, when asked, he can only support with “I heard this from patients who have tried it”. One type of fantasy is that there is wisdom in the collective consciousness – argumentum ad populum.

From what I’ve seen, doctors – even regular MD’s – sprinkle at least a few fantasy-based concepts throughout their practice. Some, obviously, are worse than others (no names, please).

I’d suggest that when it comes to reality-based or fantasy-based (or SBM/EBM vs quackery) we are better off labeling the practice rather than the practitioner. This would help “conventional” practitioners by pointing out that some of their practices are not reality-based. Whether or not they abandon these practises, they would at least be aware that they were dabbling in fantasy-based medicine.

There’s some heavy irony. The issue of tone was brought up in the blog post itself, so contributing to a discussion on that matter is hardly hijacking.

The blog post responded to Zilberberg‘s raising the “issue” of tone, a standard evasive technique used by those who can’t defend the substance of their arguments or appreciate how jerky they’re being themselves…and trolls.

Meanwhile, even though you claim to have “dedicated years of [your] life to studying the dynamics of real social movements,”

It’s a fact, to which my doctorate attests.

you chose to be petty, dredge up irrelevances, be an accessory to slander, and speculate on where I have and haven’t been banned,

Good grief. It was a warning to posters here who may be unfamiliar with you. Stop jumping into any opening anywhere you’re still tolerated to tone-wank.

rather than actually contributing knowledge of your studies pertaining to the tone issue.

There is no tone issue. All of us seem quite content with our tone – if we weren’t, we would change it.* If there’s anything people who’ve seen you and McCarthy in action recognize, it’s that it’s impossible to engage with you obsessive kooks in any productive way.

*If other people’s tone is so upsetting to you, maybe you should start a blog about it. You could call it something like “You’re Not Helpi

SC (Salty Current): “It was a warning to posters here who may be unfamiliar with you.”

It was an attempt to derail the thread with ad hominems. period. Yes, pointing out to PZ that his daughter was calling other people “retards” was probably not the best idea in the world, and I probably didn’t pick the most diplomatic way to say that Ophelia Benson was using the stoning of a girl in an fallacious appeal to emotion. None of those things is pertinent to what I cited in comment #58.

Now if you have something to say that is relevant to the topic of this thread, say it.

@SC (Salty Current), #92: If you wish to complain about “nonsense,” I suggest that you not repeat other people’s lies (i.e. comment #76).

Anyway …

Trish Gannon:

If you have science-based medicine on the one side (regardless of how that medicine is implemented), then wouldn’t other types of treatment, not based on science, be faith-based medicine?

I wish. On the Friendly Atheist blog, a commenter “chicago dyke,” very much a non-believer, wrote:

i bought a homeopathic remedy on the advice of a friend. i took a few drops before, and in the middle of class, and my violent coughing fits stopped, instantly. a girlfriend of mine (PhD biochemistry, JD science law) is allergic to cat dander. she always had coughing fits when she visited a house with cats. i gave her the cat dander relief homeopathic remedy; she quit coughing and her eyes stopped watering immediately. i have other examples but i doubt they will have any impact on someone like you. oh, and both of us are and always have been atheists and have never subscribed to any âspiritualâ or ânature worshipâ philosophies.

It’s less a divide between science-based and “faith-based” as it is science-based versus “seems to work,” whether it seems to work because of placebo effect, or because a supposedly homeopathy remedy is adulterated with a real active ingredient (or just isn’t dilute enough), or whatnot.

“Faith-based” is good – I could go with that. The only problem with the dichotomy of “science-based” and “faith-based” (or fantasy-based) is that there is actually a third type of medicine.

There are a lot of treatments that haven’t been subjected to rigorous scientific trials, often because they were in common use before medicine was as science-oriented as it is now. For example, it would be difficult (or unethical) to do a placebo-controlled trial of appendectomy vs “sham surgery” (a surgical placebo) for appendicitis (although there have been trials of immediate appendectomy vs antibiotic therapy and delayed surgery for appendicitis). Similarly, it would be exceedingly difficult to recruit subjects for a study to see if anesthesia was better than placebo for patients undergoing surgery.

For some of these treatments, the best we can do is what we would call an “ecological study” in my field – comparing two “ecosystems” that are different in the studied variable. For example, you could compare outcomes of people diagnosed with appendicitis between Christian Scientists who refuse surgery and people who have an appendectomy.

Also, there are treatments or recommendations that haven’t yet been tested but have sufficient clinical evidence (usually anecdotes) and biological plausibility to support their use. A good example would be the use of antibiotics in middle ear infections (otitis media). For decades, the “standard” was to treat these infections with antibiotics because it “made sense” – these were bacterial infections and otitis media occasionally leads to very bad complications.

More recently, however, there have been a number of studies showing that antibiotics don’t shorten the course of the infection or prevent complications in uncomplicated otitis media. This has led to a re-examination of the use of antibiotics and the practise seems to be changing.

At any rate, there are a number of reality-based medical practises that are supported by clinical experience and have biological plausibility but have not been scientifically studied. This is why there is such a clamor about science-based medicine (SBM) vsevidence-based medicine (EBM) or – if I may be so bold – reality-based medicine.

@JJ: But isn’t that still faith-based? I don’t mean faith in god here, simply faith as in “evidence of things not proven.” I have a lot of friends who believe in homeopathy, chiropractic and massage and when asked, their basic justification is that even if it doesn’t make sense, they still believe it. To me, that’s faith, regardless of whether or not any god enters the picture. (For many of these people, nature takes on the role of God, but only nature as they perceive it.)

@Prometheus: thank you for the clarification. I feel that evidence-based medicine still has basic science behind it, at least in that for it to work, it doesn’t violate any known scientific principles. Which might make it “scientifically plausible medicine”?

Trish: “But isn’t that still faith-based? I don’t mean faith in god here, simply faith as in ‘evidence of things not proven.'”

But chicago_dyke thought it was proven, at least in the sense that it seemed to work. Therein lies the rub. It’s not necessarily so much a matter of faith as people trusting in their experiences and their friends’ experiences, which unfortunately, can be all too misleading.

(BTW, in chicago_dyke’s case, I would not be surprised if she took ephedra, which would work, but just not be very safe. IIRC, that’s why one corresponding conventional medication is pseudoephedrine, which is chemically similar to ephedrine but not as risky. Yes, I know ephedra isn’t really homeopathic, but people often mix up herbal meds and homeopathic ones.)

You certainly didn’t say anything pejorative and I apologize if my comment seemed that way. I’m starting a new job (yeah!) so my comments have been a little more rushed than usual. I was merely picking up on the title of the show you mentioned.

I prefer the division of medical techniques into three categories as Prometheus mentioned in #95 because it reminds us (or at least keeps us hoping) that there are some useful things still to be learned. I do think any technique needs to at least have a demonstrable effect to get lumped into the “not yet sufficiently studied” category.

Any technique that can be debunked by an elementary school age girl doesn’t deserve a million dollar grant from the Federal government to study it.

This is where science-based medicine gets the edge over evidence-based medicine IMHO.

The biggest problem in respect to tone is that I know of hardly good ways of telling someone that they are “full of crap.”

Here are a couple of suggestions you may take or leave as you wish:
– Check your data!
– According to everything we know from physics, geology, biology, and astrophysics, it seems highly unlikely.
– Can you give evidence for that and a reason why that evidence says what you say it says?
– You’re wrong.
– You’ve used that term incorrectly.
– I knew Galileo. Galileo was a friend of mine. You, sir, are no Galileo.

@Trish, #100: Fundamentalism is probably not a bad analogy for the people who are heavily into alt-med, especially for those into the more extreme treatments like enemas, chelation, and whatnot. On the other hand, quackery has this bad tendency to seep into the mainstream, especially through celebrities like Oprah, Huffington Post, word of mouth, and so on. I doubt that the mainstream users are fundamentalist so much as misinformed.

@JJ: But isn’t that still faith-based? I don’t mean faith in god here, simply faith as in “evidence of things not proven.”

That’s exactly why I would avoid the term “faith-based” as a way to refer to the woo. Properly, it should mean stuff that people do merely out of faith in the practitioner or the philosophy behind it or the encouragement of a friend, but when the term “faith-based” already has religious baggage; in particular, it has a technical meaning to refer to things associated with an organized religion. (Compare “faith-based initiative” or “faith-based charity.”) There’s too much precedent for that usage; we don’t intend to limit the term to simply religiously motivated therapies, but that will be the implication.

A lot of people (including some atheists; this isn’t a uniquely religious problem) have difficulty separating “faith” from “religion”, and even more difficulty recognizing when they are applying faith in a secular context. Many people think if there’s no god talk, there’s no faith involved, and so they think they’re being smart, which is a very dangerous condition. This is perfectly ordinary human behavior, and it is the lynchpin of a great many scams and frauds, and also well-intentioned nonsense such as homeopathy.

On further reflection, I think that calling fantasy-based medicine “faith-based” has at least one serious flaw: a frighteningly large portion of the US population might see “faith-based” as a positive description.

Even in my secular little world, there are people – who are otherwise educated and rational – who feel that “faith-based” programs, initiatives and treatments should be accorded a little extra respect and deference simply because they are “faith-based”. This would be the opposite of what I hope to achieve with the term “fantasy-based”.

A fantasy isn’t any less a fantasy because it is shared by millions (see: folie Ã plusieurs) or because it is enshrined in books, bricks or stone.

But doesn’t medicine pride itself on being resistant to change? Isn’t the thinking that current practice is the best currently known practice? It takes years for bits of knowledge emerging from studies to be demonstrated repeatedly, and then quite a few more years from having good evidence for it to filter into fairly common usage. Presumably conventional medicine thinks it is a positive thing that it doesn’t flip flop with every new study/case study.

If you’re not resistant to change, then you must not think much of what you are currently doing.

I suspect that this is a reason that conventional medicine doesn’t always meet the needs of people who are extremely ill.

No. You must be thinking of acupuncture, homeopathy and “Traditional Chinese Medicine” (TCM), which pride themselves on being practised unchanged for centuries (although this isn’t actually true about acupuncture or TCM).

“Isn’t the thinking that current practice is the best currently known practice?”

Yes. And when new data arrive, those current practises are reviewed and, when appropriate, modified.

“It takes years for bits of knowledge emerging from studies to be demonstrated repeatedly, and then quite a few more years from having good evidence for it to filter into fairly common usage.”

Sometimes it does and sometimes new practises are rapidly incorporated from relatively meagre data. This is both good and bad, since history shows that the early results are more likely to be wrong than later, more carefully thought-out studies. As a result, some of the rapidly-adopted medical practises have been later dropped as newer and better studies failed to show their efficacy or safety.

“Presumably conventional medicine thinks it is a positive thing that it doesn’t flip flop with every new study/case study.”

See above. Early studies often (usually) have small subject numbers and – because of the natural human bias toward publishing positive results over negative results – are more likely to err in favor of the treatment studied. For that reason, there is a tendency – not a rule – to wait until early results are verified. While this may result in a better treatment being delayed, it also prevents worse treatments from being adopted.

Science isn’t perfect, but it is self-correcting. “Unconventional medicine” doesn’t wait for the data – in fact, it usually doesn’t bother collecting data at all. That’s why it relies so much on testimonials. It’s also why it isn’t very effective. Remember, popularity doesn’t equal efficacy. Blood-letting was a very popular treatment – among the general population – for centuries.

“If you’re not resistant to change, then you must not think much of what you are currently doing.”

Not true. If you are driving someplace, would you say that you don’t think much of your current route if you are readily willing to change direction if the data (road signs, for instance) suggest you are heading the wrong way? Religion – and “alternative medicine” – require faith that the “revealed” path is the correct one, regardless of the data. Real medicine follows the data.

“I suspect that this is a reason that conventional medicine doesn’t always meet the needs of people who are extremely ill.”

While there may be treatments under study that will eventually be shown to be better than those in current use, only time (and experimentation) can show which those are. This is a false dichotomy, because there is no evidence that “unconventional medicine” (“alternative medicine”?) is any better. In fact, the available data suggest that “alternative medicine” is worse than “conventional” (real) medicine, even (or especially) for “people who are extremely ill”.